Deans and deaning in a changing world.

Much has been written about the threats to medical schools and teaching hospitals, but less attention has been given to what these changes mean to the individuals who lead these institutions. In the belief that the quality of leadership of academic medical centers, especially medical schools, will help determine the future of these institutions, the author assesses the situation of deans today. He first discusses the dramatic decrease in the tenures of deans over the last 20 years and reviews the evidence for some of the possible reasons that this has happened, such as possible changes in the personal characteristics of deans (not a factor), their salaries (not a factor), the inflated titles and increasing power of deans, and the greatly expanded sites of the operations that deans now govern (caused by the enormous increase in the health care establishment and corresponding increases in medical schools). However, the author maintains that these reasons do not sufficiently account for the "administrative distress" that has affected the deanery. Causes for such distress include expectations that are too high, a constituency that is too broadly based, the dean's stunted intellectual life, unreasonable boundaries, a level of authority not commensurate with responsibility, and a faculty prone to second-guessing. The author concludes by stating that the dean must set the agenda for action by the medical school, indicates some main items of that agenda (such as promoting diversity in the physician workforce), and then offers a variety of "personal tips" to help deans survive, such as getting a good administrative assistant, talking to people one-on-one, and following up on whatever one does. He ends on a lighter note with advice to deans for personal survival, such as taking breaks, rationing travel, and planning for life after deaning.

Medical education in the 1990s--and beyond: a view from the United States.

American medical education is under continued study, and reforms are being suggested to improve it. The current paper reviews the standard U.S. medical school curriculum and discusses suggestions for change. Medical education must become more student- and learning-oriented, must place more emphasis on primary care, and must use new settings for education. The paper also examines the reasons that medical schools fail in their education mission.

It's report card time again.

The author, the outgoing president of the AAMC, presents report cards on how the academic medicine enterprise is faring today and how it may fare in the year 2000 by assigning grades to four spheres of activity: Manpower gets a D today, for the following reasons: (1) There are still far too many specialists and too few primary care physicians, and the problem may be worsening; (2) the proportion of underrepresented minorities is still too low in medical schools and the physician workforce, but there are encouraging signs that this problem may be lessening, thanks to schools' efforts to fulfill the mandate of the AAMC's Project 3000 by 2000; (3) student indebtedness is increasing, a situation that affects some students' choices of specialties. By the year 2000, the grade for manpower will rise to a C, since most Americans will have access to care, and there will be some--but not dramatic--improvement in the generalist-specialist balance. Effectiveness of medical school faculties gets a C today, mainly because although faculties have grown with no corresponding increase in students, there has been no significant increase in time or effort devoted to teaching. By the year 2000, the faculty grade will rise to a B, since the faculty will be leaner and may teach better, tenure will have become rare, especially in clinical departments, and faculty practice activities will not usurp academic activities to the extent they do today. Research gets a B+ today for solid accomplishments in the face of major constraints.(ABSTRACT TRUNCATED AT 250 WORDS)

The future of internal medicine.

Internal medicine may be in its twilight because it has failed to address the shortage of primary care physicians by training more general internists. Data from several sources indicate that progressively fewer persons are entering general internal medicine as opposed to its subspecialties. The reasons for this decline include adverse experiences in medical school, an unfavorable patient mix, declining incomes, and increasing hassles in caring for patients. A series of reforms, such as improving the teaching in medical school, strengthening divisions of general medicine, and establishing financial incentives, are proposed to reverse this trend. Other actions that must be taken include stopping the proliferation of subspecialty certificates, designating and accrediting primary care tracks, and cutting subspecialty positions. Internal medicine's fate is in its own hands, and the discipline must reorient itself to conform to societal needs.

An American's view of Canadian medical education.

Undergraduate medical education in Canada and the United States is remarkably similar, except for the fact that Canadian medical schools are supported by their provincial governments. However, the systems diverge sharply at the postgraduate level. In Canada, the number and specialty mix of residents are negotiated by medical schools in response to educational and social needs; in the United States, these factors are largely determined by hospital service needs. The Canadian systems of accreditation, certification and payment for medical education after graduation are much simpler than those of the United States, and the accreditation and certification systems are more objective. In addition, the US system promotes subspecialization and a costly specialty imbalance, whereas Canada's system has achieved an appropriate balance of specialists and generalists. In general, Canadian medical education appears to be simpler, more accountable and more socially responsive.